Basic Information
| Provider Information | |||||||||
| NPI: | 1871610311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | AIDA | ||||||||
| MiddleName: | MARLENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7481 | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915107481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184455211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2550 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182447257 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | MFTI 53319 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225C00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
No ID Information.